Village Surgery
New Patient Registration Form
Today’s Date:
Please complete this confidential questionnaire (one for each member of the family to be registered with the Practice).
Please complete in BLOCK CAPITALS and tick the boxes as appropriate.
If you are newly arrived in this country, please bring your passport to confirm your date of birth and entitlement to
NHS treatment.
Please complete a separate form for each family member to be registered.
Full Name:
NHS number (if known):
Mr / Mrs / Miss / Ms / Other……..
Telephone Number:
Address and Postcode
Mobile Number:
E-mail Address:
Next of Kin:
Next of Kin Contact Number:
Date of Birth:
Previous surname if different:
Previous Address
Town & Country of Birth:
Previous Postcode:
Previous Doctor Telephone No.
Previous Doctor Name & Address:
Previous
data
released?
Yes
No
If applicable, date you
first came to live in Britain:
If you are registering a child under 5, do you wish the child to be
registered with the Doctor for Child Health Surveillance?
Yes
No
If returning from
Armed Forces:
Your Service or Personnel Number
Your Enlistment Date
Are you or a family
member in the Armed
Forces or a Veteran?
Yes
No
Do you have a Nominated
Pharmacy for electronic
prescriptions?
Yes
(if so please let the reception staff
know if you wish to change to a local
pharmacy)
No
Your Ethnic Origin:
White (UK)
White (Irish)
White (Other)
Asian
Other Mixed
Background
(select one)
Caribbean
African
Indian /
Brit Indian
Pakistani /
Brit Pakistani
Bangladeshi / Brit
Bangladeshi
Other Asian
Background
Other Black
Background
Chinese
Other
Ethnic Category
not stated
Your main or 1st language
Spoken / Understood:
(select one)
English
Hindi
Gujurati
Urdu
Bengali
/Sytheti
Punjabi
Polish
Ukrainian
French
German
Spanish
Other:
(Please
Specify)
Smoking, Alcohol Consumption and Exercise:
Are you currently a
smoker?
Yes
No
If so, how many cigarettes / cigars /
tobacco do you smoke in a week?
If you are a smoker and want to stop, we hold a
smoking cessation service in practice.
No. times per
week
How often do you exercise?
Have you ever been a
smoker?
Yes
No
How much alcohol do you drink in a
week (Units)?
(One unit = 1 small glass of wine, a
single measure of spirits, or 1/2 a
pint of beer)
Type(s)
of
exercise:
1. How often do you have eight or more drinks on one occasion? (please circle)
Never
Less Than Monthly
Monthly
Weekly
Daily or Almost Daily
2. How often during the last year have you been unable to remember what happened the night before
because you had been drinking?
Never
Less Than Monthly
Monthly
Weekly
Daily or Almost Daily
3. How often during the last year have you failed to do what was normally expected of you because of your
drinking?
Never
Less Than Monthly
Monthly
Weekly
Daily or Almost Daily
4. Has a relative or friend, a doctor or other health worker been concerned about your drinking or suggested
you cut down?
No
Yes
(if yes was it)
in the last year or over a year ago
Your Medical Background:
Do you suffer from any
chronic diseases (such
as Asthma, CHD,
Diabetes, Epilepsy, High
Blood Pressure etc..?
Please list any tablets,
medicines or other
treatments you are
currently taking:
(incl. dose + frequency)
Diabetes
Are there any
serious diseases that
affect your Parents,
Brothers or Sisters
(tick all that apply)
Heart Attack
Breast Cancer
Heart attack under age of 60
High Blood Pressure
Thyroid Disorder
Bowel Cancer
Asthma
Stroke
Any other important Family Illness?
Specific Needs:
Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking
the appropriate action:
Please state any Sensory
Impairment you have
(i.e. Speech, Hearing, Sight):
Are you an ‘Assistance Dog’ User?
Please state any Physical disabilities
you have:
Please state any Mental disabilities
you have:
Please state any requirements you
have to be able to access the
Practice premises
Please state any Religious or
Cultural needs:
Do you require the help of a
Translator / Interpreter?
Please state any specific nutritional
requirements you have:
Please state any allergies and
sensitivities you have:
Please state any phobias you have:
Person Cared For Contact Details:
If you are a Carer, please state the
name / address / phone number of
the person you care for:
Carer Contact Details:
If you have a Carer, please state
their name / address / phone
number and sign here if you wish us
to disclose information about your
health to your Carer.
Signed:
Date:
If you wish to register as a NHS Organ Donor please go to www.uktransplant.org.uk or call 0300 123 23 23.
If you wish register as a NHS Blood Donor please go to www.blood.co.uk
Summary Care Records.
The NHS are changing the way your health information is stored and managed.
The NHS Summary Care record is an electronic record of important information about your health.
It will be available to health care staff providing your NHS Care. An information pack has been provided.
Yes
No
More Time Required to decide:
Are you happy to have a
Summary Care Record?
Patient Participation Group
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the
Practice.
If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation
Group Application Form to be given to you at your initial consultation.
Yes, I am interested in becoming involved in the Practice Patient Participation Group
(Please tick the “Yes” Box)
Patient
Signature:
Yes
Signature on
behalf of Patient:
Your physical examination will include having your height, weight and blood pressure taken from the
machine in the waiting area. Please hand your ticket in with this registration form to one of our
receptionists. When handing in these forms please bring a form of photographic id and a utility bill.
Thank you for completing this form
For more information about the services we offer, please refer to our practice leaflet
or see our website: www.villagesurgerysilksworth.nhs.co.uk
Leaflet given #8CE
Named GP #67DJ
ID Seen